MEDICARE: RUFUS GONZALES PSYCHOTHERPAY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	071007450	IL
2	261QM0850X	Adult Mental Health Clinic/Center	071007450	IL

General Provider Information

NPI Number	:	1740795897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUFUS GONZALES PSYCHOTHERPAY, LLC

Provider Business Mailing Address
First Line	:	6238 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1202
Country	:	US
Telephone Number	:	708-512-4854
Fax Number	:

Provider Business Practice Location Address
First Line	:	6238 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1202
Country	:	US
Telephone Number	:	708-512-4854
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUFUS R GONZALES
Credential	:	PHD
Telephone Number	:	708-512-4854

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	12/12/2017

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